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A hernia occurs when abdominal contents protrude through a weakened area of the muscle and connective tissue that make up the abdominal wall.
Common types include umbilical and inguinal hernias. Less common are epigastric and femoral hernias. Symptoms may range from a painless bulge to considerable pain, swelling and discolouration. Treatment will normally involve surgery to repair the weakened abdominal wall.
Serious complications can occur when hernias become incarcerated or irreducible (can’t be pushed back through the abdominal wall) which can lead to a strangulated hernia (where the blood supply to the hernia is cut off). A strangulated hernia is a surgical emergency requiring an urgent operation.
Approximately 75 - 80% of all hernias are inguinal hernias, which can occur at any age. Approximately 95% of all inguinal hernias occur in males.
An inguinal hernia occurs when a defect in the inguinal canal allows the abdominal contents (usually part of the bowel) to protrude, causing a bulge. The inguinal canal is a tubular passage through the lower abdominal muscles in the groin. In men the inguinal canal contains the spermatic cord and blood vessels. In women it contains ligaments and lymphatic vessels.
An inguinal hernia can occur because of a defect in the inguinal canal that is present at birth (congenital) or because of any factor that increases the pressure within the abdomen, such as:
- Excessive, long-term coughing
- Excessive, long-term sneezing
- Straining due to constipation
- Trauma or lifting heavy objects (this causes less than 5% of hernias).
Factors that indicate an increased risk of developing an inguinal hernia include:
- Being a smoker
- Having an undescended testicle
- Having other family members with hernias
- Having had an inguinal hernia in the past.
Signs and symptoms of an inguinal hernia can vary from person to person. Some have virtually no symptoms, while others have significant symptoms. The most common sign of an inguinal hernia is a bulge or lump in the groin. Men may also have a lump, and sometimes swelling, in the scrotum.
The bulge or lump may be painful and the pain may worsen when coughing, sneezing, lifting or standing for a long time. The lump may become bigger when coughing, bending or straining. The lump may become smaller, and the pain decrease, when lying down.
The skin over the hernia may become swollen and red. When the hernia restricts blood flow to the area the skin may look grey or blue.
Umbilical, femoral and epigastric hernias
Umbilical hernias most commonly occur in infants but may also develop in adults. They are characterised by bulging around the belly button and may be more pronounced when the infant cries or coughs. In infants, umbilical hernias are normally painless but they may cause discomfort for adults.
Most infants’ umbilical hernias will close of their own accord by age 2 or 3. However, surgical repair may be required if they haven’t disappeared by age 4-5 or if they develop in adults.
A femoral hernia occurs when abdominal contents are forced out of the abdomen through the femoral canal - a tube-shaped channel in the groin near the top of the thigh - forming a bulge that’s usually the size of a grape.
Femoral hernias tend to occur in older people. They are also more common in women, thought to be related to the weakening of the abdominal tissues during pregnancies.
The triggers of femoral hernias are similar to those of inguinal hernias – heavy lifting, straining and coughing. All femoral hernias require surgical treatment because they have a high risk of becoming strangulated.
Epigastric hernias appear in a line between the bottom of the breast bone and the belly button and will normally be no larger than a golf ball in size.
When the abdominal contents protruding through the hernia cannot be gently pushed back in, the hernia is said to be incarcerated or irreducible. This can lead to the blood supply to the bowel being cut off. When this occurs, the hernia is said to be strangulated. This can cause the bowel tissue to die and can cause severe pain at the site of the hernia. This may be accompanied by nausea and vomiting due to obstruction of the bowel.
This situation is a surgical emergency requiring an urgent operation because of the risk of gangrene.
Inguinal hernia surgery
An inguinal hernia that causes few symptoms and can easily be pushed back in may be treated without surgery. However, after examination and diagnosis by a doctor most people will be advised to have the hernia repaired surgically. This will avoid the risk of complications occurring.
There are a number of different ways of repairing an inguinal hernia. The “traditional” surgical repair is called a herniorrhaphy. This "open" surgical technique involves making a small incision over the hernia. The protruding abdominal contents are returned to the abdominal cavity. The hernia is then repaired by either stitching the muscle layers together or by closing it with a synthetic mesh patch. This procedure is usually performed under a general anaesthetic, but may be performed under local or spinal anaesthetic.
Herniorrhaphy can be done on a day-stay basis or may involve a 1-2 day stay in hospital. This will depend upon the individual and the surgeon’s recommendation.
The most common “modern” surgical technique for repairing an inguinal hernia is laparoscopic hernia repair. This "closed" surgical technique uses a small, narrow telescope (a laparoscope) to see the hernia from inside the abdominal cavity. Three small incisions are made in the groin and lower abdomen. The laparoscope is inserted through one incision and surgical instruments through the other incisions. The surgeon is able to see the hernia on a television screen and uses the surgical instruments to repair the inguinal hernia with a synthetic mesh patch.
This procedure can be performed under local, spinal or general anaesthetic and is usually performed as a day-stay procedure. Laparoscopic hernia repair has a faster recovery time than the traditional herniorrhaphy. A return to normal activities is usually achieved within one week.
Postoperative care and activity guidelines for both types of surgical repair should be discussed and outlined by the surgeon prior to surgery and before discharge from hospital.
Inguinal hernias can recur, even after surgical repair. Recurrence rates after a laparoscopic hernia repair are less than those for a herniorrhaphy. However both rates of recurrence are low. A doctor should be consulted if recurrence of the inguinal hernia is suspected.
Umbilical Hernia Surgery
If surgery is required, a small incision is made at the base of the bellybutton. The herniated tissue is returned to the abdominal cavity, and the opening in the abdominal wall is stitched closed. Most people are able to go home within a few hours after surgery and resume typical activities within two to four weeks. Recurrences are unlikely.
Femoral and Epigastric Hernia Surgery
Femoral hernia surgery is generally performed through an incision over the hernia itself or on the lower abdomen and involves opening the femoral canal, returning the protruding intestine to the abdomen, and then repairing the defect in the canal that caused the hernia. The top of the femoral canal may be reinforced by a mesh made of a synthetic material that does not irritate the body.
A femoral hernia repair is routinely performed as a day case, without the need for an overnight stay in hospital. The type of anaesthesia will depend on the exact operation and the preferences of the surgeon and patient.
Epigastric hernia surgery repairs the weakness in the abdominal wall and will routinely be done as a day case.
Abel, M.E., Glassman, S.L., Harris, R.J. & Gibson, T.J. (1999) The hernia surgery book. San Bruno: The StayWell Company
CareNotes (2007) Inguinal hernia (Disease/Disorder overview). In the Health and WellnessResourceCenter. Thompson Gale.
O’Toole, M.T. (Ed.) (2013) Mosby’s Dictionary of Medicine, Nursing & Health Professionals. (9th ed.) St. Louis: Elsevier Mosby
Last Reviewed – 17 April 2013